2003.pdf

Breast Augmentation 2003 Breast Augmentation 2003 PHOTO The patient shown in the photograph has which of the following types of ptosis? (A) Pseudoptosis (B) First-degree ptosis (C) Second-degree ptosis (D) Third-degree ptosis The correct response is Option C. The patient in the photograph has seco...

Breast Augmentation 2003 Breast Augmentation 2003 PHOTO The patient shown in the photograph has which of the following types of ptosis? (A) Pseudoptosis (B) First-degree ptosis (C) Second-degree ptosis (D) Third-degree ptosis The correct response is Option C. The patient in the photograph has second-degree ptosis. In this condition, the nipple is located beneath the inframammary fold, but above the lowest level of the breast. In patients with pseudoptosis, also known as glandular ptosis, the breast mass descends from behind the nipple-areola complex, but the nipple remains above the level of the inframammary fold. First-degree ptosis is characterized by descent of the nipple to the level of the inframammary fold. Positioning of the nipple at the lowest point on the breast is consistent with third-degree ptosis. References 1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:57-97. 2. Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg. 1993;91:657-662. 3. Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg. 1976;3:193203. In patients with polymastia, accessory mammary structures are most frequently found at which of the following sites? (A) Neck (B) Axilla (C) Thigh (D) Buttock (E) Vulva The correct response is Option B. Accessory mammary structures are found along the embryonic milk line, which forms on the ventrolateral body wall from the axilla to the groin. These include most supernumerary breasts, which are most often found in the axilla, just above or below the normal breast, or in the groin. True accessory mammary structures occur less frequently in the inner surfaces of the upper arm and inner side of the thigh or the vulva. Ectopic mammary structures are found outside of the embryonic milk line and represent either true ectopia or displacement of the milk line. Ectopic breast tissue has been reported in the midline and on the face, ear, neck, back, buttock, and outer thigh. References 1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:57-97. 2. Georgiade NG, Georgiade GS, Riefkohl R. Esthetic breast surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6:3839-3896. 3. Skandalakis JE, Gray SW, Ricketts R, et al. The anterior body wall. In: Skandalakis JE, ed. Embryology for Surgeons. Baltimore, Md: Williams & Wilkins; 1994:540-593. Which of the following factors is most critical in determining the need for breast contouring following removal of breast implants? (A) Age of the patient (B) Amount of breast tissue overlying the implant (C) Degree of preoperative ptosis (D) Size of the areola (E) Size and position of the implant The correct response is Option C. The degree of ptosis seen preoperatively is most important in determining the need for breast contouring following explantation. Because ptosis remains relatively unchanged following implant removal, contouring should be considered in women who have ptosis that is classified preoperatively as grade II or III. The thickness of residual breast parenchyma best determines the viability of performing breast contouring concomitantly with explantation. The breast tissue should have a minimum thickness of 4 cm to allow for vascularity of the overlying skin and of the separated glandular-nipple flap. This is best assessed by performing a breast pinch test superiorly and inferiorly. In determining the type of mastopexy that is most appropriate for each patient undergoing explantation, the elasticity of the skin, size and positioning of the implant, and size of the areola should be assessed. Circumareolar mastopexy is an option in women with areolae that are larger than 50 mm. References 1. Rohrich RJ, Beran SJ, Restifo RJ. Aesthetic management of the breast following explantation: evaluation and mastopexy options. Plast Reconstr Surg. 1998;101:827. 2. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg. 2001;107:1294. Which of the following findings is most likely in a patient with Poland syndrome? (A) Anomalies of the feet (B) Bilateral abnormalities of the ribs (C) Breast hypertrophy (D) Hypoplasia of the pectoralis major muscle (E) Polythelia The correct response is Option D. Poland syndrome is a congenital anomaly that is characterized by unilateral aplasia or hypoplasia of the pectoralis major muscle and adjacent musculoskeletal components. Chest wall anomalies can also be unilateral and include aplasia or hypoplasia of the breast or nipple, partial agenesis of the ribs and sternum, and anomalies of the shoulder girdle. Ipsilateral hand anomalies are common. In severe forms of the disease, the pectoralis, latissimus, and serratus muscles are completely absent. Poland syndrome typically occurs sporadically and its etiology is not fully understood. Men and women are affected equally. Despite the absence of structures of the chest wall, patients have minimal physical disability. Appropriate reconstructive options include transfer of the latissimus in men and women, with the addition of submuscular augmentation mammaplasty in women. References 1. Argenta LC, Vanderkolk C, Friedman RJ, et al. Refinements in reconstruction of congenital breast deformities. Plast Reconstr Surg. 1985;76:73-82. 2. Seyfer AE, Icochea R, Graeber GM. Poland's anomaly: natural history and longterm results of chest wall reconstruction in 33 patients. Ann Surg. 1988;208:776782. In a patient with breast implants, each of the following has been shown to interfere with screening mammography EXCEPT (A) Baker III capsular contracture (B) implant location (C) implant size (D) native breast volume The correct response is Option C. Several factors have been shown to affect the findings on mammography in women with breast implants. The positioning of the implant and the degree of associated capsular contracture have been known to influence the quantity of breast tissue that can be visualized. In addition, one study showed an increase in the amount of tissue that can be visualized postoperatively in a subset of women with small native breast volume. Therefore, it is important for patients who have breast implants to undergo mammographic evaluation at specialized centers experienced at obtaining mammograms using either compression or displacement (Eklund) techniques, which maximize visualization of the breast parenchyma. The size of the implant has not been shown to affect the amount of breast tissue that can be visualized on mammography. References 1. Eklund GW, Busby RC, Miller SH, et al. Improved imaging of the augmented breast. Am J Radiol. 1988;151:469-473. 2. Handel N, Silverstein MJ, Gamagami P, et al. Factors affecting mammographic visualization of the breast after augmentation mammaplasty. JAMA. 1993;269:987-988. 3. Silverstein MJ, Handel N, Gamagami P, et al. Mammographic measurements before and after augmentation mammaplasty. Plast Reconstr Surg. 1990;86:11261130. Breast Reconstruction - 2003 In a 48-year-old woman who recently underwent bilateral reduction mammaplasty, histologic evaluation of resected tissue shows findings consistent with invasive ductal carcinoma. Which of the following factors will best determine the most appropriate next step in the management of this patient? (A) Age of the patient (B) Initial tumor margins (C) Location of the tumor (D) Total volume of tissue resected (E) Tumor size The correct response is Option B. In this patient who has invasive ductal carcinoma, the initial tumor margins will determine the most appropriate next step in management. If the tumor was not completely excised during the original reduction mammaplasty procedure, completion mastectomy is recommended. Because of the potential for shifting of the tissues following reduction, possible tumor seeding, and residual lymphatic spread, this procedure is advocated for nearly all patients who did not undergo complete tumor excision at the time of breast reduction. Even if the tumor is excised completely with adequate margins, the axillary region should be evaluated because chemotherapy and radiation therapy may still be required. Occult breast carcinoma has been identified in as many as 2% of women undergoing reduction mammaplasty. In addition, occult carcinoma was found in 4.6% of women who underwent a "balancing reduction" following mastectomy. There is some discrepancy in the incidence of occult carcinoma related to the inclusion or exclusion of in situ lesions. Women who have occult malignancies identified during breast reduction are more likely to be younger and to have lobular tumors without palpable lymph nodes. The age of the patient, total volume of tissue resected, location of the tumor, and tumor size have not been shown to influence treatment options independent of the surgical margins obtained at the time of reduction mammaplasty. References 1. Brown MH, Weinberg M, Chong N, et al. A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg. 1999;103:1674. 2. Jansen DA, Murphy M, Kind G, et al. Breast cancer in reduction mammoplasty: case reports and a survey of plastic surgeons. Plast Reconstr Surg. 1998;101:361 3. Tang CL, Brown MH, Levine R, et al. Breast cancer found at the time of breast reduction. Plast Reconstr Surg. 1999;103:1682-1686. 4. Tang CL, Brown MH, Levine R, et al. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Plast Reconstr Surg. 1999;103:1687-1690. A 45-year-old woman is scheduled to undergo mastectomy of the right breast followed by reconstruction using a free TRAM flap. She has a 15 pack/year history of cigarette smoking. This patient is at increased risk for development of each of the following postoperative complications EXCEPT (A) abdominal flap necrosis (B) fat necrosis (C) hernia (D) mastectomy skin flap necrosis The correct response is Option B. The free TRAM flap is frequently advocated for breast reconstruction in high-risk patients, including those who smoke, because of its enhanced blood supply; however, patients who smoke are still at increased risk for development of complications. One large retrospective study showed that patients who smoked were at greater risk for developing hernia and necrosis of the mastectomy skin flap and abdominal flap when compared with nonsmokers undergoing breast reconstruction with the free TRAM flap. Because patients who had a 10 pack/year or greater history of smoking were at greatest risk for perioperative complications, it has been suggested that reconstruction should be delayed until the patient has stopped smoking for at least four weeks. Studies have shown no significant increase in the rate of fat necrosis, flap loss, or vessel thrombosis in patients who smoked when compared with nonsmokers. References 1. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg. 2000;105:274. 2. Chang LD, Bunke G, Slezak S. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12:467. 3. Reus WF, Robison MC, Zachary L. Acute effects of tobacco smoking on blood flow and cutaneous micro circulation. Br J Plast Surg. 1994;37:213. 4. Van Adrichem LN, Hoegen R, Hovious SE, et al. The effect of cigarette smoking on the survival of free vascularized and pedicled epigastric flaps in the rat. Plast Reconstr Surg. 1996;97:86. Breast Reduction - 2003 A 16-year-old girl has had rapid, asymmetric enlargement of the left breast over the past year. On physical examination, an 18-cm mass can be palpated; there is ptosis and stretching of the nipple-areola complex. The veins are prominent and dilated, and there is ulceration of the skin superolateral to the nipple. Mammography shows a dense, circumscribed, homogeneous mass that encompasses the entire breast. Which of the following is the most appropriate management? (A) Hormone therapy (B) Enucleation (C) Subcutaneous mastectomy (D) Simple mastectomy (E) Reduction mammaplasty The correct response is Option B. This 16-year-old girl has fibroadenoma, which is the most common neoplasm of the breast in adolescents. Giant fibroadenomas are typically solitary, firm, nontender, benign lesions that develop at or soon after the onset of puberty. They are larger than 5 cm in diameter and double in size within a short time. Rapid enlargement of one breast is characteristic. Prominent veins are noted over the arc of the tumor; some patients develop skin ulcerations because of the pressure caused by the fibroadenoma. Enucleation is curative, and the risk for local recurrence is minimal. Hormone therapy would only stimulate growth of the glands within the breast. Mastectomy is excessive and unnecessary in patients with giant fibroadenoma. Reduction mammaplasty is indicated for management of juvenile breast hypertrophy, which is characterized by diffuse enlargement of the breast without a palpable mass or nodes. References 1. McGrath MH. Benign tumors of the teenage breast. Plast Reconstr Surg. 2000;105:218. 2. Souba WW. Evaluation and treatment of benign breast disorders. In: Bland KI, Copeland EM, eds. The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia, Pa: WB Saunders Co; 1991:715. Sensation to the nipple-areola complex is provided primarily by which of the following nerves? (A) Anterior cutaneous nerve from T3 (B) Anterior cutaneous nerve from T4 (C) Lateral cutaneous nerve from T4 (D) Medial cutaneous nerve from T5 (E) Posterior cutaneous nerve from T5 The correct response is Option C. Sensation to the nipple-areola complex is primarily provided by the lateral cutaneous nerve from T4. The innervation of the skin of the breast is segmental and is derived from the dermatomes associated with breast development. Knowledge of this innervation is crucial before performing breast surgery. The upper breast receives its sensation from the supraclavicular nerves that originate from the third and fourth branches of the cervical plexus. The medial and inferior aspects of the breast are innervated by small medial branches of the anterior cutaneous nerves. The lateral cutaneous branches course subcutaneously to provide sensation to the midclavicular region and contribute to the innervation of the areola. References 1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:57-97. 2. Georgiade NG, Georgiade GS, Riefkohl R. Esthetic breast surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6:3839-3896. 3. Skandalakis JE, Gray SW, Ricketts R, et al. The anterior body wall. In: Skandalakis JE, ed. Embryology for Surgeons. Baltimore, Md: Williams & Wilkins; 1994:540-593. A 40-year-old woman has cyanosis of the right nipple one hour after undergoing bilateral breast reduction with removal of 1500 g of tissue on each side. Which of the following is the most appropriate management? (A) Observation (B) Application of leeches (C) Hyperbaric oxygen therapy (D) Release of the sutures (E) Conversion of the nipple-areola complex to a split-thickness skin graft The correct response is Option D. The findings seen in this patient are consistent with necrosis of the nipple-areola complex. This condition can be caused by direct devascularization of the breast mound, torsion, or direct pressure on the nipple and areola. Appropriate management includes immediate decompression with release of the sutures and operative exploration. Excision of the nipple-areola complex with subsequent defatting and conversion to a full-thickness skin graft is indicated for those patients who have ischemia of the breast mound identified on operative exploration. Free nipple grafting may be considered to decrease the risk for necrosis of the nipple-areola complex in women undergoing breast reduction with an estimated volume of resection of more than 1500 g on each side, a nipple transposition length of 25 cm or greater, or associated risk factors such as smoking or diabetes mellitus. Although leeches can be used to relieve venous insufficiency, this process would need to be undertaken over several days to be effective. Hyperbaric oxygen therapy increases the oxygen content of the tissue but is also a lengthy process. References 1. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. 1999;104:806. 2. Spear SL, Burkes JB, Forman D. Experience with reduction mammaplasty following breast conservation surgery and radiation therapy. Plast Reconstr Surg. 1998;102:1913. Gynecomastia is an adverse effect of administration of each of the following agents EXCEPT (A) cimetidine (Tagamet) (B) digitalis (Digoxin) (C) minocycline (Minocin) (D) spironolactone (Aldactone) (E) zolpidem (Ambien) The correct response is Option E. Many agents have been linked to gynecomastia, such as amphetamines, cimetidine, digitalis, haloperidol, isoniazid, methyldopa, opiates, progestins, spironolactone, and tricyclic antidepressants. Associated conditions include obesity, liver disease, kidney failure, adrenal tumors, hyperthyroidism, and hypothyroidism. Gynecomastia can also be caused by increased estrogen levels (men with testicular tumors or who use androgen-based agents) or decreased estrogen levels (men with Klinefelter syndrome or who undergo orchiectomy). Zolpidem has not been shown to be a cause of gynecomastia. References 1. Bostwick J. Plastic and Reconstructive Breast Surgery. Saint Louis, Mo: Quality Medical Publishing; 1990;1:465-516. 2. Sifton DW, ed. Physicians' Desk Reference. Montvale, NJ: Medical Economics Co; 2002:2823-2825. 3. Tuerk M. Medications that cause gynecomastia. Plast Reconstr Surg. 1993;92:1411. Burns - 2003 A 30-year-old man is brought to the emergency department after sustaining second-degree burns of the trunk involving 10% total body surface area (TBSA). The burns are cleansed, and several blisters are debrided. In order to provide antimicrobial activity, which of the following dressings should be applied to the wounds? (A) Fibronectin-coated skin substitute (Transcyte) (B) Porous collagen-glycosaminoglycan membrane (Integra) (C) Silicone membrane-nylon fabric composite (Biobrane) (D) Silver-coated wound dressing (Acticoat) The correct response is Option D. Treatment of partial-thickness burns can be accomplished through cleansing of the burn and application of either an antimicrobial or occlusive dressing. Most patients are treated with silver sulfadiazine (Silvadene); however, if a sulfa allergy is present, bacitracin, polymyxin/bacitracin (Polysporin), or mupirocin (Bactroban) can be used. Acticoat is a dressing material coated with a thin soluble layer of silver ion; it reportedly provides antimicrobial activity for as long as five days. The greatest advantage is a decrease in the number of dressing changes, with a subsequent decrease in pain, as well as decreased cost. Biobrane and Transcyte are occlusive dressings that can be used for management of clean second-degree burns as long as they are applied within the first 24 hours. These dressings do not provide antimicrobial activity. Biobrane consists of a nylon fabric containing chemically bound collagen that is partially imbedded in a silicone film. As blood and serum clot within the nylon fabric, it adheres to the wound until epithelialization occurs, and then it sloughs. Transcyte consists of cultured human dermal fibroblasts on a semipermeable membrane bonded to nylon mesh. The mesh allows for growth of the dermal tissue, and the membrane forms a synthetic epidermis. Integra is a bioengineered dermal substitute consisting of a bilayered membrane system. It is used for skin replacement after debridement of deep partial-thickness or full-thickness burns. The dermal replacement layer comes from bovine tendon cartilage, and the epidermal replacement is a synthetic silicone polymer that is removed following degradation of the dermal layer. A thin skin graft is then placed on the "neodermis." References 1. Kao CC, Garner WL. Acute burns. Plast Reconstr Surg. 2000;105:2482-2491. 2. Yin HQ, Langford R, Burrell RE. Comparative evaluation of antimicrobial activity of Acticoat antimicrobial barrier dressing. J Burn Care Rehab. 1999;20:195-200. Administration of anti-inflammatory agents to patients who have sustained frostbite is most likely to result in which of the following beneficial effects? (A) Decreased production of prostaglandin I2 (B) Decreased production of thromboxane B2 (C) Increased production of prostaglandin F2a (D) Increased production of prostaglandin I2 The correct response is Option B. Based on theories regarding the pathophysiology of frostbite injury, adverse changes that occur within the microvasculature at the site of injury are thought to be caused by inflammatory mediators. The prostaglandins thromboxane B2 and prostaglandin F2a are thought to induce microvascular thrombosis because they cause platelet aggregation and vasoconstriction. In contrast, the prostaglandins I2 and E2 have antiplatelet activity, resulting in vasodilation. It is thought that the frostbite injury increases production of thromboxane B2 and decreases production of prostaglandin I2, resulting in an imbalance in favor of microvascular thrombosis. Experimental studies have shown increased levels of these mediators within the frostbitten tissue in both experimental animal models and in the blister fluid of frostbite patients. In addition, studies have demonstrated that specific thromboxane inhibitors can increase the survival of threatened tissue. Because anti-inflammatory agents, such as aspirin and ibuprofen, inhibit cyclooxygenases, administration of these agents will decrease production of thromboxane B2 and prostaglandin F2a and thus block their harmful effects. However, an adverse effect of these agents is their inhibition of prostaglandin I2 and prostaglandin E2 production, which limits their protective effect. References 1. Heggers JP, McCauley RL, Phillips LG, et al. Cold induced injury: frostbite. In: Herndon DN, ed. Total Burn Care. Philadelphia, Pa: WB Saunders Co; 1996:408414. 2. Ozyazgan I, Tercan M, Melli M, et al. Eicosanoids and the inflammatory cells in frostbitten tissue: prostacyclin, thromboxane, polymorphonuclear leukocytes, and mast cells. Plast Reconstr Surg. 1998;101:1881-1886. 3. Robson MC, Smith DJ. Cold injuries. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:849-866. Monoclonal antibodies have been shown to limit the depth of burn injury by inhibiting neutrophil adhesion in which of the following zones? (A) Zone of adherence (B) Zone of coagulation (C) Zone of hyperemia (D) Zone of stasis The correct response is Option D. Patients with burn injuries have destruction of tissue proportionate to the length of time that the tissue has been exposed to the heat source and the temperature at the surface of the skin. There are three zones that can be described to delineate the pathophysiology of burn injury. The zone of coagulation is that area of the skin that is exposed to the highest temperature, resulting in irreversible, uniform necrosis of cells. This zone involves the burn eschar and extends downward. The zone of stasis surrounds the zone of coagulation; in this area, the cells sustain less direct injury initially. Instead, progressive injury occurs following the development of ischemia and subsequent impairment of blood flow. This zone is characterized by the formation of microthrombi within platelets, endothelial swelling, neutrophil adherence, deposition of fibrin, and vasoconstriction, leading to eventual cell death. However, because injury in this zone is potentially reversible, there have been numerous experiments involving the zone of stasis in an attempt to limit burn depth. Several experimental animal studies have shown that antibodies directed to receptors on neutrophils can block their adherence to vessel walls, preventing microvascular occlusion and leukocyte-mediated endothelial injury. The total burn surface area is subsequently decreased. In the zone of hyperemia, there is vasodilation and increased blood flow caused by vasoactive mediators. Cellular injury in this zone is minimal and is completely reversible. The zone of adherence describes anatomic regions within the body in which skin and subcutaneous tissue are connected to the underlying fascia. It is important for the surgeon to recognize these zones when planning and performing suction lipectomy, as excessive suctioning may result in contour deformities. References 1. Bucky LP, Vedder NB, Hong HZ. Reduction of burn injury by inhibiting CD18mediated leukocyte adherence in rabbits. Plast Reconstr Surg. 1994;93:1473-1480. 2. Choi M, Rabb H, Arnaout MA, et al. Preventing the infiltration of leukocytes by monoclonal antibodies blocks the development of progressive ischemia in rat burns. Plast Reconstr Surg. 1995;96:1177-1185. 3. Kao CC, Garner WL. Acute burns. Plast Reconstr Surg. 2000;101:2482-2492. 4. Williams WG, Philips LG. Pathophysiology of the burn wound. In: Herndon DN, ed. Total Burn Care. Philadelphia, Pa: WB Saunders Co: 1996:63-70. A 40-year-old man sustains deep partial-thickness and full-thickness burns over 45% total body surface area (TBSA). Following fluid resuscitation for 24 hours, his temperature is 38.9%C (102.1%F), pulse rate is 120 bpm, respirations are 24/min, and blood pressure is 105/60 mmHg. Serum leukocyte count is 18,000/mm3 and urine output is 70 mL/hr. Which of the following is the most likely cause of these findings? (A) Bronchopneumonia (B) Burn wound sepsis (C) Inadequate fluid resuscitation (D) Inadequate pain control (E) Systemic inflammatory response The correct response is Option E. This 40-year-old man with burn injuries has findings consistent with systemic inflammatory response syndrome (SIRS), an inflammatory condition that can be caused by soft-tissue trauma, bacteremia, sepsis, ischemia, or pancreatitis. SIRS typically occurs in patients who have burns of more than 30% total body surface area (TBSA); the cell damage caused by the burn often incites the inflammatory reaction. Hyperactivity of the immune system causes alterations in the metabolic, cardiovascular, gastrointestinal, and coagulation systems. Affected patients have hypermetabolism and exhibit increased cellular, endothelial, and epithelial permeability and microthrombosis. The diagnosis of SIRS can be made in any patient with burn injury who meets at least two of the following criteria, occurring as a sudden alteration above baseline levels in the absence of any other condition: 1. Body temperature lower than 36%C (96.8%F) or higher than 38.5%C (101.5%F) 2. Heart rate greater than 90 bpm 3. Respirations greater than 20/min, or carbon dioxide partial pressure (pCO2) less than 32 mmHg 4. Serum leukocyte count less than 4000/_L, greater than 12,000/_L, or containing more than 10% band forms Although the precise mechanism that causes SIRS is unknown, the humoral or cellular immune system activates the onset of symptoms. Because the complement system is typically activated in burn patients, this may interact with the coagulation, fibrinolysis, and kallikrein-kinin systems to trigger the onset of the syndrome. Other critical mediators include heat shock proteins, tumor necrosis factor-alpha, the interleukins IL-1, IL-6, and IL-8, and endotoxin. Bronchopneumonia would be unlikely in a patient who sustained burn injuries only 24 hours ago and more often occurs in the second week following injury. Burn wound sepsis occurs when proliferating microorganisms exceed 105 per gram of tissue and can be characterized by fever, tachycardia, and leukocytosis, but again this would not appear within the first 24 hours after injury. Inadequate fluid resuscitation is unlikely in a patient with adequate urinary output. Inadequate pain control would cause tachypnea and tachycardia, but not fever or leukocytosis. References 1. Hinder F, Traber DL. Pathophysiology of the systemic inflammatory response syndrome. In: Herndon DN, ed. Total Burn Care. Philadelphia, Pa: WB Saunders Co; 1996:207-216. 2. Kao CC, Garner WL. Acute burns. Plast Reconstr Surg. 2000;101:2482-2492. 3. Mannick JA, Rodrick ML, Lederer JA. The immunologic response to injury. J Am Coll Surg. 2001;193:237-244. To minimize the risk for hypertrophic scar formation and subsequent skin contractures in a patient who has sustained partial-thickness burns of the neck, attempts at healing by second intention should be limited to a maximum of how many weeks? (A) 1 (B) 2 (C) 3 (D) 4 (E) 6 The correct response is Option C. To minimize the risk for development of hypertrophic scars and subsequent skin contractures in a patient who has sustained partial-thickness burns of the neck, the wound should not remain open for more than three weeks. According to the results of one study, hypertrophic scars formed in 33% of patients whose wounds healed within three weeks, compared with 78% of patients whose wounds were left open for more than 21 days. Burn scar contractures of the neck can be released using Z-plasty, local flaps, or thick split-thickness or full-thickness grafts. The surgeon may need to release the platysma with the scar in order to restore full extension. Long-term postoperative splinting and compression are essential for graft take. Tissue expansion of unburned adjacent skin is another alternative for resurfacing the burned area. References 1. Cole JK, Engrav LH, Heimbach DM, et al. Early excision and grafting of face and neck burns in patients over 20 years. Plast Reconstr Surg. 2002;109:1266. 2. Deitch EA, Wheelahan TM, Rise MP, et al. Hypertrophic burn scars: analysis of variables. J Trauma. 1983;23:895. 3. Jonsson CE, Dalsgaard CJ. Early excision and skin grafting of selected burns of the face and neck. Plast Reconstr Surg. 1991;88:83. 4. Robson MC, Barnett RA, Leitch IO, et al. Prevention and treatment of post burn scars and contracture. World J Surg. 1992;16:87. A 25-year-old laborer sustains a burn of the dorsal aspect of the dominant right hand in a fire. Physical examination shows a deep partial-thickness burn that involves the entire dorsal aspect of the hand. Which of the following is the most appropriate management? (A) Early excision of the burn wound and split-thickness skin grafting (B) Coverage of the burn wound with a silicone membrane-nylon fabric composite (Biobrane) (C) Aggressive topical wound care and occupational therapy (D) Excision of the burn wound and coverage with a groin flap (E) Excision of the burn wound and delayed split-thickness skin grafting The correct response is Option A. In this patient who has sustained a deep partial-thickness burn of the hand, the most appropriate management is early excision of the burn eschar followed by split-thickness skin grafting over the excised portions. An early return to full hand function is especially crucial in this patient, a laborer who has sustained a burn to his dominant right hand. Occupational therapy can be initiated immediately after excision and skin grafting to maximize hand function, allowing him to return to work as soon as possible. Synthetic dressings should not be used to cover deep partial-thickness burns. Conservative therapy will only delay the appropriate treatment and make hand therapy more difficult. Coverage with a groin flap is an excessive, unnecessary procedure in this patient. Skin grafting should be delayed only if the depth and extent of the patient's burn injuries are unknown. In these situations, a waiting period of seven days may be beneficial. References 1. Press B. Thermal, electrical, and chemical injuries. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:161-189. 2. Smith MA, Munster AM, Spence RJ. Burns of the hand and upper limb Ð a review. Burns. 1998;24:493. PHOTO A 47-year-old man sustains a high-voltage electrical burn injury to the left upper extremity; a photograph is shown above. Physical examination shows swelling and tenseness of the forearm; there is no circumferential eschar. An exit wound is noted on the left foot. Adequate fluid resuscitation has been performed, and the patient is stable. Which of the following is the most appropriate immediate management of the right forearm and hand? (A) Observation (B) Splinting (C) Escharotomy (D) Fasciotomy (E) Amputation The correct response is Option D. Electrical injuries involving a charge of greater than 1000 volts are often misleading because the mildness of the superficial wounds frequently masks the serious underlying problems. Bone and muscle have greater resistance and thus generate significant heat, and the necrotic processes of these tissues are often hidden under viable skin. Serial excision of tissue is required to address this complication. Affected patients also have marked edema and rapidly increasing compartment pressures, which inhibit vascular inflow and can further worsen tissue necrosis. Muscle necrosis may lead to myoglobinuria, which if left untreated can result in myoglobin-induced renal failure. To prevent this life-threatening complication, the urine must be alkalized with administration of sodium bicarbonate, and urinary output must remain at a constantly high rate. Fasciotomies of the hand and forearm should be performed immediately for tissue salvage; the surgeon should continue to assess the viability of the tissue in the hand and forearm following fasciotomy. Observation is obviously inadequate and even dangerous in a burn patient with compartment syndrome. Similarly, splinting alone will not prevent further injury to the extremity. Although escharotomy does not relieve compartment syndrome, it is a recommended first step in patients who have burn injuries with constricting eschar. Amputation prior to complete demarcation may be required in patients with infected or completely necrotic tissue. Reference 1. Achauer BM, Applebaum R, Vandercam VM. Electrical burn injury of the upper extremity. Br J Plast Surg. 1994;47:331-340. PHOTO A 2-year-old child has the findings shown in the photograph above six days after sustaining a full-thickness burn injury to the left hand when the hand was immersed in boiling water. Silver sulfadiazine dressings have been applied since the time of injury. Which of the following is the most appropriate next step in management? (A) Continued use of silver sulfadiazine dressings for three weeks (B) Tangential excision and coverage with split-thickness skin grafts (C) Tangential excision and coverage with full-thickness skin grafts (D) Fascial excision and coverage with full-thickness skin grafts (E) Coverage with cryopreserved acellular dermal homograft and epidermal grafts The correct response is Option B. In this 2-year-old child who has a full-thickness burn, the most appropriate management is tangential excision to a level at which punctate bleeding occurs, followed by split-thickness skin grafting. The depth of the burn can be determined by serial examination; in this case, after six days, the wound is not vascularized and has not become epithelized. Because burns that have not healed 21 days after initial injury are associated with a significant risk for hypertrophic scarring and contracture, this child's burn should be excised tangentially to the level of punctate bleeding. In addition, early skin grafting decreases the risk for scarring and permanent stiffness in patients with burns of the hand and increases the rehabilitation potential. As implied above, continued application of silver sulfadiazine dressings is not appropriate in this patient. Any available full-thickness skin for grafting would most likely not be sufficient for coverage of this full-thickness burn involving most of the hand and forearm; a full-thickness graft is recommended instead for smaller areas that will contract only minimally. Although acellular dermal homograft has been shown to be beneficial in larger burns, its effects are limited in patients with burns limited to the hand who have other donor sites available. References 1. Brcic A. Primary tangential excision for hand burns. Hand Clin. 1990;6:211219. 2. Sheridan RL, Hurley J, Smith MA, et al. The acute burned hand: management and outcome based on 10-year experience with 1047 acute hand burns. J Trauma. 1995;38:406-411. Cleft Lip/Palate - 2003 During embryologic development, which of the following structures arises from the frontonasal processes? (A) Columella (B) Nasal bridge (C) Nasal septum (D) Nasal tip (E) Philtrum Reproduced with permission of Arey LB, ed. Developmental Anatomy. 26th ed. Philadelphia, Pa: WB Saunders Co; 1970. The correct response is Option B. During embryologic development, the nasal structures form during the sixth week of gestation as the frontonasal and medial nasal processes enlarge and coalesce in the midline. Any abnormalities occurring during this gestational stage are likely to lead to the development of a cleft nasal deformity or other nasal deformities. References 1. Arey LB, ed. Developmental Anatomy. 26th ed. Philadelphia, Pa: WB Saunders Co; 1970. 2. Gosain AK, Moore FO. Embryology of the head and neck. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:223-236. 3. Johnston MC, Bronsky PT, Millicovsky G. Embryogenesis of cleft lip and palate. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;4:2525. Cosmetic - Blepharoplasty - 2003 A 54-year-old man is undergoing a browlift procedure for correction of lateral orbital hooding. After elevating the forehead skin, residual fullness is noted at the lateral orbit. A soft mass can be palpated. Which of the following anatomic structures is the most likely cause? (A) Frontal bone (B) Lacrimal gland (C) Lateral orbital fat pad (D) Orbicularis oculi muscle The correct response is Option B. Excessive fullness of the lateral orbit, especially in men, is most often caused by the lacrimal gland; this structure is implicated in 10% to 15% of patients with lateral orbital fullness. Residual fullness can be diminished by resuspending the gland beneath the supraorbital rim. This procedure involves suturing the capsule to the periosteum posteriorly to anteriorly. Excision of the lacrimal gland is not recommended because it can lead to keratoconjuctivitis sicca. The frontal bone is a potential cause of frontal bossing but would be firm to palpation. A contour burr can be used intraoperatively to improve bossing. The lateral orbital fat pad is located beneath the lower eyelid and would not cause fullness in the lateral orbital region. The orbicularis oculi muscle is a soft, mobile structure that surrounds the orbit; it would not cause an isolated, firm mass. References 1. Beer GM, Kompatscher MD. A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthet Plast Surg. 1994;18:65-69. 2. McLeish WM, Anderson RL. Cosmetic eyelid surgery and the problem eye. Plast Reconstr Surg. 1992;19:357-368. A 50-year-old woman says she has "sad eyes" two years after undergoing foureyelid blepharoplasty. She smokes two packs of cigarettes daily and developed skin hyperpigmentation after undergoing laser facial resurfacing seven years ago. Physical examination shows excess scleral show bilaterally; retraction of the skin following snap-back testing is slowed. Which of the following is the most appropriate management? (A) Eyelid massage and taping (B) Release of outer lamellar scars and coverage with a thin split-thickness skin graft (C) Lateral canthopexy (D) Malar augmentation (E) Extended SMAS rhytidectomy The correct response is Option C. This patient has excess scleral show and poor skin retraction on snap-back testing two years after undergoing blepharoplasty. Lateral canthopexy is most likely to improve the "sad eye" appearance seen in this patient. Tightening of the lower eyelid will give the patient a more youthful appearance and correct the conjunctival complications. Lateral canthopexy is associated with minimal scarring and few complications. In patients with more severe scleral show, grafting may be required for increased support of the lower eyelid. Massage and taping of the eyelid are unlikely to be effective in a patient who has had scleral show for two years. Full-thickness skin grafts can be transferred to improve scleral show and decrease the potential for graft contraction that occurs with split-thickness grafts; however, hyperpigmentation is a likely complication of grafting. Malar augmentation should be performed concomitantly with an eyelid tightening procedure; implantation alone will worsen scleral show. Smoking is a relative contraindication to extended submuscular aponeurotic system (SMAS) rhytidectomy. References 1. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85;971. 2. Patipa M. The evaluation and management of lower eyelid retraction following cosmetic surgery. Plast Reconstr Surg. 2000;106:438-453. In a 55-year-old woman who underwent transcutaneous blepharoplasty of the lower eyelids one month ago, which of the following is the most likely unfavorable result? (A) Contour irregularity (B) Diplopia (C) Lagophthalmos (D) Malpositioning of the lower eyelids (E) Tear trough deformity The correct response is Option D. The most common unfavorable result following transcutaneous blepharoplasty of the lower eyelids is malpositioning of the eyelid. Malpositioning can result from excessive removal of skin, muscle, or fat, injury to the orbicularis oculi muscle, or scar contracture. Knowledge of the anatomy of the lower eyelid is essential for the surgeon performing the transcutaneous blepharoplasty procedure. The tarsus and canthal ligaments act to suspend the eyelid, while the pretarsal fibers of the orbicularis oculi muscle support the lower eyelid. Careful preoperative evaluation and intraoperative use of appropriate techniques will prevent postoperative malpositioning. Eyelid massage and/or corticosteroid injections can be used to resolve early malpositioning. Eyelid taping and use of Frost sutures have also been advocated. If conservative measures are unsuccessful, tarsal stripping or grafting procedures or wedge tarsectomy may be required to restore the appropriate eyelid position. Contour irregularities typically result from inadequate or excessive resection of fat. Diplopia can be caused by intraoperative injury to the inferior oblique muscle. Affected patients typically have vertical diplopia that becomes worse on gaze to the contralateral side. Because this condition typically resolves spontaneously, observation is recommended. Patients with lagophthalmos cannot close the eyelids. This problem is associated with excessive resection of skin. Tear trough deformity also results from excess skin excision, which is less common than inadequate excision but is also more difficult to correct. Grafting procedures are required for reconstruction in patients who have this deformity. References 1. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg. 1990;85:971-981. 2. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. Philadelphia, Pa: WB Saunders Co; 1999:429-456. Cosmetic - Chemical Skin Peel - 2003 A 55-year-old woman has had pain, swelling, and erythema of the left arm for the past 24 hours. She underwent mastectomy and axillary lymph node dissection on the left four years ago. On examination, she is afebrile. Laboratory studies show a leukocyte count that is within normal limits. Which of the following is the most appropriate management? (A) Lymphatic massage (B) Application of a compression bandage and elevation of the extremity (C) Topical application of an antibiotic (D) Intravenous administration of an antibiotic (E) Incision and drainage The correct response is Option D. In this patient who has had the spontaneous onset of cellulitis of the arm after undergoing axillary lymph node dissection, the most appropriate management is intravenous administration of an antistreptococcal antibiotic. Fever and leukocytosis are typically associated with cellulitis but are not required to make the diagnosis, as many of these patients will be afebrile and will not have an increased leukocyte count or absolute neutrophil count on serologic testing. Antistreptolysin O titer may be positive. Although lymphatic massage and compression and elevation of the extremity are useful in controlling the lymphedema associated with lymph node dissection, these measures will not treat cellulitis. Antibiotic therapy should not be based on the results of blood or tissue aspirate cultures because these often do not yield any growth. Topical application of an antibiotic will not effectively treat cellulitis. Incision and drainage of the affected site is not indicated. References 1. Calkins ER. Nosocomial infections in hand surgery. Hand Clin. 1998;14:531545. 2. Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. 1992;93:543-548. A 55-year-old woman is scheduled to undergo 30% trichloroacetic acid peeling for eradication of fine perioral rhytids. Which of the following is the most likely complication? (A) Cardiac arrhythmias (B) Herpetic reactivation (C) Hyperpigmentation (D) Hypertrophic scarring (E) Loss of sweat glands The correct response is Option C. Potential complications of trichloroacetic acid peeling are rare, but include infection, scarring, and changes in skin pigmentation. Pigmentary changes are most common. The optimal chemical peel creates a controlled partial-thickness wound; however, peels that destroy tissue through the entire epidermis are most likely to result in hypopigmentation. Hyperpigmentation, which is typically transient, results from inflammatory changes that are thought to be caused by trauma to melanocytes, resulting in excessive stimulation. Cardiac arrhythmias are associated with phenol peeling, and herpetic reactivation is usually a complication of laser resurfacing. Trichloroacetic acid peeling provides a superficial peel that would not result in hypertrophic scarring or permanent loss of sweat glands. References 1. Brody HJ. Complications of chemical resurfacing. Dermatol Clin. 2001;19:427438. 2. Greenbaum SS. Chemical peeling, injectable collagen, implants, and dermabrasion. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:597-608. A 52-year-old woman wishes to undergo phenol chemical peeling for improvement of the facial skin surface. She has a history of alcohol abuse and liver disease. Laboratory evaluation shows a prothrombin time of 12 sec and a serum aspartate aminotransferase level of 68 U/L. Which of the following complications is most likely in this patient? (A) Cardiac arrhythmias (B) Delayed wound healing (C) Excessive bleeding (D) Hypertrophic scarring (E) Permanent hyperpigmentation The correct response is Option A. Phenol (carbolic acid) is an aromatic hydrocarbon derived from coal tar. It is one of the most common agents used in chemical peeling and is often combined with other topical agents to increase absorption and decrease inflammatory skin response. However, patients who undergo phenol peeling should be monitored closely because of the potential for the development of cardiac toxicity associated with increased levels of phenol in the blood. Because phenol is detoxified in the liver, adverse cardiac effects are more likely to occur in this patient who has a history of alcohol abuse and liver disease. In addition, only small areas should be treated at one time; if chemical peeling is performed on more than one half of the face in less than 30 minutes, arrhythmias or other severe cardiac complications can occur. These complications have been noted in as many as 50% of treated patients. Other, less common complications in patients undergoing phenol peeling include hypopigmentation, transient splotchy hyperpigmentation, prominence of the skin pores, telangiectasias, erythema, and milia. Delayed wound healing and hypertrophic scarring are rare complications of deep peeling. Bleeding does not occur. References 1. Gross BG. Cardiac arrhythmias during phenol face peeling. Plast Reconstr Surg. 1984;73:590. 2. Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg. 1979;63:44. A 65-year-old woman desires correction of fine facial rhytids. Which of the following agents is most effective for skin rejuvenation in this patient? (A) Ascorbic acid (B) Glycolic acid (C) Hyaluronic acid (D) Retinoic acid (E) Trichloroacetic acid The correct response is Option E. Because trichloroacetic acid produces moderate exfoliation in concentrations of 15% to 35%, it is the most appropriate agent for improvement of facial rhytids. The other agents listed provide only mild or no exfoliation. Ascorbic acid (vitamin C) has been shown in some clinical studies to improve photoaged skin but is not yet widely used. Glycolic acid and other alpha-hydroxy acids are used for chemical peeling. These agents provide some improvement of fine rhytids, but overall results in patients with photoaged skin remain controversial. Hyaluronic acid is used in other countries as a filler substance for lip augmentation, as well as for correction of rhytids. It has also shown promise as an adjunct treatment for depressed scars. However, it is not yet approved for use in the United States. Retinoic acid is also used for skin rejuvenation but has been shown to provide only moderate improvement in fine rhytids. Clear histologic improvement in photoaging has not been confirmed. References 1. Clark CP III. New directions in skin care. Clin Plast Surg. 2001;28:745-750. 2. Fusco FJ. The aging face and skin: common signs and treatment. Clin Plast Surg. 2001;28:1-12. Use of which of the following agents is CONTRAINDICATED prior to dermabrasion? (A) Alpha-hydroxy acid (B) Glycolic acid (C) Hydroquinone 4% (D) Isotretinoin (E) Tretinoin The correct response is Option D. Isotretinoin (Accutane, also referred to as 13-cis retinoic acid) is contraindicated in a patient who is to undergo dermabrasion. Isotretinoin is an oral retinoid that is used to treat acne by suppressing keratinization and the function of sebaceous glands, thereby diminishing the oiliness of the skin. In patients undergoing isotretinoin therapy, dermabrasion or laser resurfacing should be deferred for at least one year following discontinuation of the drug, because delayed healing and hypertrophic scarring may occur. Alpha-hydroxy and glycolic acids are mild agents typically found in many overthe-counter skin creams. These agents are not contraindicated in patients undergoing dermabrasion. Hydroquinones are typically administered preoperatively and postoperatively to prevent hyperpigmentation. Tretinoin is used for skin preparation in patients scheduled to undergo dermabrasion or laser therapy. References 1. Greenbaum SS. Chemical peeling, injectable collagen, implants, and dermabrasion. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:597-608. 2. Harmon CB. Dermabrasion. Dermatol Clin. 2001;19:439-442. 3. Rubenstein R, Roenigk HH, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Acad Dermatol Surg Oncol. 1986;15:280. Which of the following best describes a patient with Fitzpatrick type II skin? (A) Usually burns, tans with difficulty (B) Sometimes burns, tans moderately (C) Rarely burns, tans easily (D) Never burns, deep pigmentation The correct response is Option A. Fitzpatrick's system is used for classifying patients according to skin type in order to assist them in the promotion of skin care and the prevention of solar damage. The classification is also helpful in determining treatment protocols for topical and laser skin care. This method of classification is based on melanin content, inherent pigmentation, and sensitivity to ultraviolet light during an initial, unprotected sun exposure. Patients with a lower Fitzpatrick skin type tend to have less melanin pigmentation within their skin. A table representing this classification system is shown below. Skin Type I II III IV V VI Skin Characteristics Color White Always burns, never tans White Usually burns, tans less than average Sometimes burns mildly, tans about White average Rarely burns, tans more than White average Brown Rarely burns, tans profusely Black Never burns, deep pigmentation Reference 1. Fitzpatrick TB. The validity and practicality of sun reactive skin types I-VI. Arch Dermatol. 1988;124:869. Cosmetic Facelifts Brow - 2003 A 40-year-old woman desires improvement of transverse rhytids along the root of the nose. The most appropriate surgical procedure is resection of which of the following muscles? (A) Corrugator supercilii (B) Frontalis (C) Orbicularis oculi (D) Procerus The correct response is Option D. The transverse rhytids along the root of the nose can be improved with resection of the procerus muscle, which originates from the surface of the upper lateral cartilage and nasal bones and inserts into the skin and glabellar region. Contraction of the procerus pulls the forehead downward and the root of the nasal tip upward, causing wrinkling. The corrugator supercilii muscles originate along the periosteum and medial orbital rim and insert into the dermis of the medial eyebrow. They contract to pull the medial brow downward, resulting in vertical glabellar wrinkling. The frontalis muscle is a vertical extension of the galea aponeurosis, which elevates the eyebrows. It inserts on the skin of the forehead, causing transverse forehead rhytids. The orbicularis oculi muscles surround the upper and lower eyelids and do not contribute to any vertical or transverse rhytids of the forehead. References 1. Flowers R, Duval C. Blepharoplasty and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:609. 2. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321. 3. Thorne CH, Aston SJ. Aesthetic surgery of the aging face. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:617. A 62-year-old woman who underwent subcutaneous superficial plane rhytidectomy with SMAS plication one week ago notices that the left side of her upper lip does not elevate when she attempts to smile. The most likely cause is injury to which of the following nerve branches? (A) Buccal (B) Cervical (C) Frontal (D) Zygomatic The correct response is Option A. This patient's inability to elevate the left side of the upper lip is most likely caused by injury to the branch of the buccal nerve that innervates the levator labii oris muscle. The buccal nerve branches, which lie superficial to the parotid fascia, are positioned immediately beneath the submuscular aponeurotic system (SMAS) as they cross the masseter muscle and can be easily injured during dissection of the SMAS. Most deficits resulting from buccal nerve injury improve spontaneously over time because of the cross-innervation that occurs in this region. Injury to the cervical branch causes weakening of the platysma, resulting in an asymmetric smile. Injury to the frontal branch manifests as eyebrow ptosis or inability to raise the eyebrow. Because this branch is likely to be terminal, the deficit is often permanent. Injury to the zygomatic branch, which is rare, leads to a decrease in facial animation in the area overlying the zygomaticus major and minor muscles. References 1. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and pitfalls. Plast Reconstr Surg. 1979;64:781. 2. Duffy M, Friedland J. The superficial plane rhytidectomy revisited. Plast Reconstr Surg. 1994;93:1392. 3. Stuzin JM. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265. PHOTO The 52-year-old woman shown in the photographs above desires facial rejuvenation. Physical examination shows malar ptosis, mildly deepened nasolabial folds, lateral orbital hooding, and prominent neck bands. Skin classification is Fitzpatrick type II. Which of the following is the most appropriate management? (A) Topical application of 0.05% tretinoin for two weeks followed by laser resurfacing (B) Rhytidectomy (C) Rhytidectomy with direct resection of the platysmal bands and nasolabial folds (D) Rhytidectomy and temporal lifting (E) Rhytidectomy, temporal lifting, and submental platysmal plication The correct response is Option E. In this 52-year-old woman who desires facial rejuvenation, rhytidectomy, temporal lifting, and submental platysmal plication should be performed concomitantly. Rhytidectomy improves static facial rhytids and diminishes mildly deepened nasolabial folds. Access to the midface for temporal lifting can be accomplished via a temporal, blepharoplasty, or standard preauricular incision. The malar fat is then elevated and sutured to the deep temporal fascia, correcting the malar ptosis. The prominent neck bands are caused by submental separation of the platysma. Plication of the muscle laterally and in the midline (through a submental incision) will alleviate these bands and diminish the potential for recurrence. Topical application of retinoic acid and laser resurfacing will not address the softtissue component of the face. Rhytidectomy alone will not correct the lateral orbital hooding. Direct resection of platysmal bands and nasolabial folds will result in visible scarring. References 1. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and upper facelift. Plast Reconstr Surg. 1996;97:928-937. 2. Duffy MJ, Friedland JA. The superficial-plane rhytidectomy revisited. Plast Reconstr Surg. 1994;93:1392. 3. Knize D. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:1321-1333. A 56-year-old woman has prominent glabellar rhytids and says that her eyelids appear "heavy." On examination, the patient has a high hair line and relatively thin hair; the eyebrows are positioned just inferior to the supraorbital rims laterally. There is mild redundancy of the upper eyelid skin. Which of the following is the most appropriate management? (A) Carbon dioxide laser resurfacing of the forehead and upper eyelid blepharoplasty (B) Open browlifting through a coronal incision, including resection of the corrugator and procerus muscles (C) Open browlifting through a hairline incision, including resection of the corrugator and procerus muscles (D) Upper eyelid blepharoplasty (E) Upper eyelid blepharoplasty and injection of botulinum toxin (Botox) into the glabellar region The correct response is Option C. The most appropriate management in this patient with "heavy" appearing eyes is open browlifting through a hairline incision, including resection of the corrugator and procerus muscles. Open browlifting will decrease the height of the forehead, and the incision can be hidden beneath the hair. Concomitant resection of the corrugator and procerus muscles will improve the glabellar rhytids. Laser resurfacing is effective for treatment of rhytids but not eyebrow ptosi